Omega-3 fatty acids seem like a cure-all for just about anything that ails patients nowadays. They're hailed for promoting better heart health, reducing inflammation, providing more lustrous hair and skin, and even promoting better mood. The question is, how beneficial are omega-3s for dry eye patients? "We're in the infancy stages
of understanding what this is and
what it does for dry eye," said Robert Latkany, M.D., founder and director, Dry Eye Clinic, New York Eye and Ear Infirmary, New York.

Right now, ophthalmologists are using the fledgling research that is available along with their clinical experience to decide whether or not they will recommend omega-3 supplementation to dry eye patients.

The research

Some recent research has tried to pin down the specific effects of omega-3 supplementation on dry eye. In a pilot, double-masked study published in March 2011 in Cornea,
investigators gave patients various doses of fish oil and flaxseed oil (TheraTears Nutrition, Advanced
Vision Research, Woburn, Mass.) for 3 months. Investigators measured patients' subjective symptoms and tested for tear breakup time and corneal staining as well as performing other tests.

Of the 36 patients included, 70% of the patients receiving treatment became asymptomatic. In the placebo group, 37% of the symptomatic patients became asymptomatic. Schirmer's testing and fluorophotometry seemed to indicate that omega-3 use increased tear secretion, according to investigators. Although those results are promising, they only begin to reveal how omega-3 might help dry eye and which patients would benefit the most, Dr. Latkany said.

Knowing how well an omega-3 product can be absorbed in the body is crucial in ensuring it will provide key health benefits to the eyes and elsewhere, Dr. Bucci said.

Although there have been
other studies related to dry eye and omega-3 supplementation, there has yet to be a large-scale clinical trial that pinpoints how omega-3 fatty acids work to treat dry eye and what kind of dosing is appropriate. Penny A. Asbell, M.D., professor of ophthalmology, director, Cornea and
Refractive Services, Department of Ophthalmology, Mount Sinai School of Medicine, New York, hopes to find those answers via a clinical trial slated to get under way with the
National Eye Institute. "With omega-3 and dry eye, we have small trials but little in the way of double-masked, randomized, controlled
trials," she said. The trial she is working on will look beyond the claims of omega-3 benefits for general health to show how the supplementation can benefit dry eye. "It behooves us to find out how this works," she said. The trial should also reveal more information on the epidemiology of dry eye, Dr. Asbell added.

At Dr. Latkany's practice, which specializes in dry eye, he routinely recommends omega-3 use. Of those who take it, he estimates that 70% become asymptomatic. However, this occurs along with the use of other treatments, such as Restasis (cyclosporine ophthalmic emulsion, Allergan, Irvine, Calif.), punctal plugs, or environmental changes. "Very few patients notice a big difference from omega-3 use alone. It would be in the single digit percentage," he said.

Dr. Latkany recommends omega-3 use the most to Sjogren's syndrome patients—who typically might have dry eyes, hair, mouth, and skin. He often finds his patients have already heard about omega-3 benefits, perhaps not specifically for dry eye but for general health.

Because of the general health benefits, Dr. Sheppard recommends omega-3 fatty acids for virtually all patients. "The American diet is notoriously deficient in the high-value foods. Rather than becoming a
dietitian, I just recommend it to everyone. It can't hurt, with the exceptions of seafood allergy and coagulation deficiency conditions," he said. Additionally, patients can use omega-3 both to help treat dry eye and help prevent other eye conditions such as age-related macular
degeneration—a condition where there is even more solid research
regarding omega-3 use and prevention of disease, he said. Dr. Sheppard typically recommends 1,000 mg of omega-3 twice daily in addition to GLA supplements, although he will encourage patients to take more if they are willing and able. That dosage amount provides both eicosapentaenoic acid and docosahexaenoic acid—
better known as EPA and DHA,
Dr. Sheppard said.

However, Dr. Sheppard also noted that patients with evaporative dry eye seem to yield the most
consistent benefits. The study he presented at ARVO intentionally focused on postmenopausal females as they represent a fairly homogeneous subpopulation that could benefit significantly from supplementation, he said.

What product works best?

Practitioners seem to have personal preferences regarding specific omega-3 products. "No single study shows yet that one product works better than the other," Dr. Latkany said. "Any well-known company that purifies its product, you'll be fairly safe with it."

However, Dr. Sheppard steers patients toward pharmaceutical-grade, mercury-free supplementation. "With a cheaper version, there's more risk for contaminants. We're recommending this at a high dose, so it's essential to be safe," he said. Dr. Bucci prefers a higher quality omega-3 product that absorbs more quickly in the body, comes from fish sources versus flaxseed, and does not contain alcohol.

There has been recent talk in the popular press about krill oil as an omega-3 source that can be better absorbed by the body, Dr. Latkany said. He has seen some of his
patients successfully use krill oil.

In the rare instances where a patient does not like fish oil, is allergic to it, or has another physician concerned about its use because the patient takes anticoagulant therapy, Dr. Sheppard recommends the use of flaxseed oil, which the patient can obtain as a gel cap or even sprinkle in powder form on food.